Provider Demographics
NPI:1790085660
Name:CARNEY, JACKSON
Entity Type:Individual
Prefix:DR
First Name:JACKSON
Middle Name:
Last Name:CARNEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3642 GLENEAGLES DR
Mailing Address - Street 2:#1H
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20906-1631
Mailing Address - Country:US
Mailing Address - Phone:301-598-3312
Mailing Address - Fax:
Practice Address - Street 1:15411 NEW HAMPSHIRE AVE
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20905-4162
Practice Address - Country:US
Practice Address - Phone:301-476-8303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-26
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD6631183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist